Childbirth Injuries and the Arbitrary 6 Weeks

The 6 week postpartum checkup taunts moms who suffered from childbirth injuries. Personally, I still couldn’t WALK without pain at my checkup. My midwives assured me I would eventually recover, which was both true and not true — TRUE because the major tears slowly healed, and progressive strength training gave me back enough function — yet, NOT TRUE because I have permanent damage, a.k.a my anatomy will always be “messed up” (that’s the technical term).

In addition to active healing efforts, passive Time was my friend. When I say “time,” I mean months, possibly years. I do not mean 6–8 weeks. Indeed, at a couple months postpartum I was still crying about how I’d never get my body back. And I never did completely. But Time rolled its eyes at my tears and slowly gifted me with physical improvement.

A recent study in the American Journal of Obstetrics and Gynecology supports my personal observation that the 6–8 week marker does NOT apply to many pelvic-floor childbirth injuries. I’ll talk about that study in a minute, but first I’ll regale you with more of my “anecdata.”

First, My “Anecdata”

I had my babies fairly close together. The first two were 19 months apart, and my last came 26 months after my middle. I thought this timing was perfectly fine.

I was naive. I didn’t fully understood how long it could take for a body to heal from childbirth injuries.

My first pregnancy was difficult and my first delivery was a bloody mess (if you think this is TMI, you are reading the wrong blog…). I got pregnant with my second child when my first giant bundle of joy was only 10 months old. I had another difficult pregnancy, now compounded by my lingering childbirth injuries and a high energy toddler. Toddlers don’t care how much you are puking or how much weight your pelvic floor can handle. Go figure.

My second delivery was just as bloody and traumatic as the first. Therefore, I thought I was “wise” to give my body more time to recover before having another child. In my mind I was prudent, but in reality my middle child wasn’t even a year and half old when I got pregnant again. In retrospect, that doesn’t really qualify as prudent. And, yes, the third pregnancy was difficult as well.

I survived (woo hoo). But, my body was all like “are you kidding me?” (Since pregnancy and childbirth sucked so much, you may be wondering why I wanted three kids. Answer: I don’t know. I’m not always a rational being. Luckily, my kids are healthy and mostly adorable, so sometimes life rewards you for being foolish).

Am I an Anomaly?

Sort of. Most women don’t give birth vaginally to two babies within 19 months, the largest 10 and half pounds. However, as women start having their first kids later in life and/or think about timing their children closer together, we will probably see more of these childbirth injuries. Therefore, we should take a moment to appreciate how long recovery can take. We should also take a moment to think about our mom forbearers who sometimes had a dozen children in a lifetime. I bet many of those women had undiagnosed and untreated prolapse or pelvic floor disorder.

Back to That Study

My particular background got me interested in that American Journal of Obstetrics and Gynecology study (called “Evaluating Maternal Recovery from Labor and Delivery: Bone and Levator Ani Injuries”). If you want to know the details, the full text is online for your reading pleasure. I’ll give the cliff notes.

The authors looked at 68 women in a longitudinal cohort study who had risk factors for levator ani muscle injury (the levator ani is made up of 3 muscles. Watch this video if you are curious about anatomy). Some of these risk factors included a long pushing stage, anal tears, and advanced maternal age. They used an MRI on these women at 7 weeks and 8 months postpartum.

They weren’t able to get MRIs for all the women, so their sample size was skewed towards older, white, and highly educated women. Nonetheless, their findings, even in this small sample, were interesting.

  • For example, at 7 weeks postpartum, 66% of the women had edema (i.e., swelling) in the pubic bone marrow, but only 14% still had swelling at 8 months postpartum.
  • At 7 weeks, 17 of the women has fractures in the bone marrow of the pubic bone, but only 2 had fractures at 8 months postpartum.

The news was less comforting for levator ani muscle tears (not to be confused with tears of the perineum).

    • 28 of the women had some form of LA (levator ani) discontinuity at 7 weeks postpartum. And, at 8 months postpartum, 25 still showed evidence of these tears.

However, what’s really interesting is that “none of the fecal or urinary incontinence measures were associated with magnitude of LA tear scores.”

But, contraction force of the LA muscles and posterior descent of the vaginal wall were “significantly” associated with more intense LA tears.

In other words, the severity of the muscle skeletal injury didn’t correlate with the severity of symptoms. The authors note that this finding goes against some previous studies. They also note that their high drop out rate was uncool (not their exact words, but I’m reading between the lines).

What Does This Mean for You or Your Patients?

I’m not sure. The study’s lead author suggests women with lingering pain should get an MRI. I’m not sure about the practicality of this advice considering our current health insurance woes. I’m also not sure extra information would drastically change treatment. Still, more information could be helpful for some women.

Also, in response to this study, a physical therapist was quoted in an NPR article, saying:

We tend to focus on the pelvis after childbirth, but we should be thinking beyond that, for instance, what is the woman’s posture like? Is she able to transition in and out of bed and can she pick up the baby in ways that minimize the stress on healing or weakened tissue? The goal is to set things up so that everything the woman is doing protects the pelvic floor and aids the healing process. It’s not only about squeezing and getting stronger. It’s a more holistic approach

I mean, maybe. However, this particular study doesn’t validate what this physical therapist says. Nor, do I think the study invalidates it. In fact, I think the study has very little bearing on the efficacy of specific physical therapy recommendations, other than to remind us some muscle tears won’t be healed by tweaking our posture or by kegeling (I’m not saying those things won’t help, just that they won’t cure).

What this study shows is that childbirth injuries can take a LONG TIME to heal, especially for women at high risk for pelvic floor levator ani injury. It also shows that tears are probably with you forever, but that edema or fractures are not. It shows that 6–8 weeks is an arbitrary recovery timeline for many women. And it might show that your degree of musculoskeletal injury doesn’t necessarily indicate your degree of pelvic floor disorder.

So, give yourself time. See a specialist (even one who uses the word “holistic” that I like to half-mock). And, move your body in ways that help you build strength without aggravating musculoskeletal injuries.

Ultimately, be proactive, but, more importantly, be patient.

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